The changes made to
the requirements for telehealth services since the start of the COVID-19
pandemic have been swift and substantial. For the first several weeks, it seems
changes were made almost daily. As time
has passed, the changes to telehealth have stabilized enough that a summary of
the current telehealth issues is possible. However, changes may still be
forthcoming so the following is a summary of the significant topics related to
providing telehealth services as of the date of this article. Physicians should
continue to monitor announcements related to telehealth requirements as changes
will surely continue to evolve.

Medicare – On
March 30, 2020, the Centers for Medicare & Medicaid Services (CMS)
announced additional temporary expansion of telehealth services to Medicare
beneficiaries. CMS’s announcement of this new reimbursement flexibility builds
on its prior expansion of telehealth services to address the COVID-19 pandemic.
Prior to the March 30, 2020 announcement, CMS announced the following: (1) the
patient location requirement was being waived to allow the patient to be in
their home or other location; (2) the audio-video link can be something as
simple as Skype, FaceTime or Facebook Messenger video calls. However, the
audio-video link has to be a real-time audio and a one-to-one video connection,
and cannot be public-facing; (3) the patient cost share can be waived at the
providers’ discretion; and (4) CMS stated it will not audit to verify that
there is an established patient relationship.

CMS announced in its
March 30, 2020 announcement that it is now also allowing Medicare beneficiaries
to receive care via telehealth by: (1) adding more than 80 services to the list
of services payable under the Medicare Physician Fee Schedule when furnished
via telehealth, including emergency department visits, initial nursing facility
and discharge visits, critical care services, home visits for new and
established patients, and physical and operational therapy services; (2)
allowing clinicians to provide Virtual Check-In services to new patients
in the same manner as they previously could provide only to established
patients; (3) allowing licensed clinical social workers, clinical
psychologists, physical therapists, occupational therapists, and speech
language pathologists to provide e-visits; (4) allowing clinicians to provide
certain services by audio phone only to their patients; (5) allowing
clinicians to provide Remote Patient Monitoring, for acute or chronic
conditions, to both new and established patients; (6) removing certain
frequency limitations on Medicare telehealth; (7) expanding the use of
telehealth to certain home health and hospice services; and (8) expanding the
definition of “homebound” so that when a physician determines that a Medicare
beneficiary should not leave the home due to suspected or confirmed COVID-19,
the patient can qualify for the Medicare Home Health benefit.

Medicare
Miscellaneous Issues – Patient consent may be obtained annually and
obtained by ancillary staff. Direct
Supervision of services, such as incident-to services, normally require that
the supervising/billing physician be in the office suite and immediately
available. However, for the duration of the PHE, direct supervision can be
provided by real-time interactive audiovisual technology.

CMS
is allowing payment for certain codes related to telehealth services because as
an example, CMS recognizes that some problems can be handled over the phone
without a face-to-face, but may require more than the 5-10 minutes. The codes
for established patients for physician or other qualified professionals
(nurse practitioners or physician assistants) include 99441 (requires 5-10
minutes of medical discussion), 99442 requires 11-20 minutes of medical
discussion), 99443 (requires 21-30 minutes of medical discussion).
Practitioners should report the E/M code that best describes the nature of the
care they are providing. Previous guidance was to use POS 02 that will cause
payment to be made at the lower facility rate. Alternatively, providers can
choose to use the POS code that most accurately reflects where the service is
performed and append modifier 95. This will cause payment to be made at the
higher non-facility rate.

Alabama
Medicaid – Medicaid normally requires separate credentialing for providers
performing telehealth; however, that restriction has been waived for the time
period for dates of service from 3/16/2020 – 4/16/2020. Medical providers may
bill established patient evaluation and management codes 99211, 99212 and 99213
for telephone consultations. Psychologists and behavioral health
professionals should bill 90832, 90834, 90837, 90846, 90847 and H2011. Verbal
consent must be obtained and documented in the medical record. These visits
will count against the patient’s office visit limit of 14 visits per year.

Blue
Cross and Blue Shield of Alabama – is allowing providers to bill for
telephone call treatment of existing patients under the established patient
office visit codes for dates of service from 3/16/2020 – 4/16/2020. They are
allowing codes up to 99213 with place of service code 02 for telehealth. No
modifier is required. The physician should be the one speaking with the patient
— not the office staff.

HIPAA – Over the past several weeks, the Office for
Civil Rights (“OCR”) has issued several notices regarding HIPAA in
light of the current COVID-19 pandemic. The OCR issued a Notification of
Enforcement Discretion for Telehealth Remote Communications during the COVID-19
Nationwide Public Health Emergency. OCR stated that it would relax its
enforcement actions with regard to compliance with certain aspects of HIPAA
(and not enforce penalties) in order to allow providers to better treat their
patients via telehealth. A health care provider that wants to use audio or
video communication technology to provide telehealth to patients during the
public health emergency can use any non-public facing remote audio or video
communication product that is available to communicate with patients. Health
care providers may use applications that allow for video chats, including Apple
FaceTime, Facebook Messenger video chat, Google Hangouts video, or Skype, to
provide telehealth without risk that OCR might seek to impose a penalty for
noncompliance with the HIPAA Rules. However, communication applications that
are public facing should not be used. OCR further stated that it would not
impose penalties against health care providers for the lack of a Business
Associate Agreement with video communication vendors. The above applies to
telehealth provided for any reason, regardless of whether the telehealth
service is related to the diagnosis and treatment of health conditions related
to COVID-19. The OCR also issued additional guidance in the form of frequently
asked questions (FAQs) which are available at https://www.hhs.gov/sites/default/files/telehealth-faqs-508.pdf.

State Licensure – Most states have greatly relaxed
or streamlined their licensing requirements and application process to make it
easier for physicians to provide telehealth services across state lines.
However, the application process and requirements for each state differ so it
is extremely important for physicians to check with each state. For example,
the state of Tennessee requires the practitioner to complete and submit an
application, which can be found at: https://www.tn.gov/content/dam/tn/health/documents/cedep/novel-coronavirus/Boards-Executive-Order-Form.pdf.
The determination is made on a case by case basis. It appears most applications
are being approved by the Tennessee Department of Health because as of the end
of March 2020 the Department had received 61 applications and approved 59
applications, denied one, and one was under review. The State of Florida, for
purposes of preparing for, responding to, and mitigating any effect of
COVID-19, permits health care professionals not licensed in Florida to provide
health care services to a patient located in Florida using telehealth, for a
period not to exceed 30 days unless extended by order of the State Surgeon
General. The exemption applies only to out of state health care professionals
holding a valid, clear, and unrestricted license in another state or territory
in the United States who are not currently under investigation or prosecution
in any disciplinary proceeding in any of the states in which they hold a
license.

While the telehealth waivers and notifications have
slowed down in recent days, it is still very important for physicians to keep
updated on the various requirements from state licensing authorities and
payors.

Jim Hoover
practices with Burr & Forman LLP and works exclusively within the firms
Health Care Industry Group and primarily handles healthcare litigation and
compliance matters.

Last night President Trump signed what is being called the second coronavirus stimulus bill. It provides for free coronavirus screening, $1 billion in additional unemployment insurance funding to all states, a bump in Medicaid FMAP, $1 billion in food aid, and two provisions to provide paid sick leave to employees.

Emergency Paid Sick Leave

This provision gives 80 hours or 2 weeks of paid sick leave to individuals who work for employers with fewer than 500 employees. This applies to all employees, both full time and part-time with part-time receiving leave equal to the average number of hours worked. There is also no tenure of employment requirement. This leave is available to workers who are:

In self-isolation because of a coronavirus diagnosis

Obtaining a diagnosis or care due to coronavirus symptoms

Complying with an order to self-isolate because of exposure to someone with coronavirus

Caring for a family member with a diagnosis or symptoms

Caring for a child without access to daycare or school because of closure.

If the employee falls under the first 3 categories, they are entitled to full pay, but if work is missed to care for a family member or a child without access to school or daycare only two-thirds of pay is due. An employer cannot force an employee to use existing, traditional sick leave first.

Emergency Family and Medical Leave Act (EFMLA)

If after the first 2 weeks, the employee needs additional days, the EFMLA will be triggered. The existing FMLA provides 12 weeks of unpaid leave, but this emergency measure would provide that up to 10 weeks of that emergency eave that would be paid. The first two weeks under EFMLA would remain unpaid and during the following 10 weeks employees would be entitled to two-thirds of their pay.

Like the emergency paid sick leave provision, EFMLA would be for those diagnosed with coronavirus, caring for a family member diagnosed, and caring for a child without access to daycare or school. Unlike the paid sick leave provision, employees must have worked for 30 days and there is a hardship exemption for small business with under 50 employees. Under the hardship exemption, the US Department of Labor is given the authority to develop regulations to exempt a small business if EFMLA threatens the viability of the business.

The United States Secretary of Labor has the authority to issue regulations for good cause to (1) exclude certain health care providers and emergency responders from the definition of eligible employee; and to exempt small businesses with fewer than 50 employees when the imposition would jeopardize the viability of the business.

Tax Credit for Employers

Employers would be eligible for a refundable tax credit of 100 percent of qualified sick leave wages paid and family leave wages paid against their employer-side payroll tax liability. Employers can claim a quarterly tax credit against payroll taxes for payments associated with these 2 provisions up to the total payroll taxes in that quarter.

Medicaid

The bill temporarily increases the Medicaid FMAP in all states by 6.2% beginning in the calendar quarter of the emergency and ending the quarter it is declared over. Coronavirus testing must also be provided with no cost sharing. Those eligible will only lose coverage if they leave the state.

The bill also creates a new Medicaid eligibility category for the uninsured. Uninsured individuals would only be eligible to receive diagnostic testing for coronavirus, no treatment, but that testing would be done at no cost and reimbursed at 100% FMAP.

Unemployment Insurance

As states expand the criteria for unemployment to include coronavirus reasons, the US Labor Department reported 281,000 new claims for unemployment insurance last week, a 70,000 jump over the previous week. The bill gives states $1 billion for unemployment insurance nationwide that will provide relief to those who are facing coronavirus-related job loss. The unemployment aid would be broken in two separate payment structures. The first 50% of the grant would be sent to states for State Unemployment Agency staffing, technology, and other administrative costs so long as the states comply with three provisions in the bill. (1) Require employers to provide notification to the potential UI eligibility to laid off workers; (2) ensure that workers can apply for benefits in person, by phone, or online; two of the three must be available; (3) the state must notify applicants when an application is received and being processed and if the application cannot be processed, what information is needed to successfully process the claim. Currently, the State of Alabama would meet the current requirements to receive their portion of the first $500 million package. The other $500 million would be reserved for an emergency grant package for those states that may have seen at least a 10% increase in unemployment. There is also flexibility built into the unemployment provision with the goal of making it easier for workers to access unemployment benefits by waiving waiting weeks and work search requirements.

States could potentially be eligible for Extended Benefits (EB) for unemployment compensation programs when the unemployment rate surpasses certain thresholds to trigger EB programs. The first extended benefits trigger could allow for an additional 13 weeks of unemployment benefits after a claimant exhausts current state benefits (14 weeks of state UI benefits).

Food Assistance

The bill adds $500 million to provide access to nutritious foods to low-income pregnant women or mothers with young children who lose their jobs or are laid off due to the COVID-19 emergency through the Special Supplemental Nutrition Program for Women Infants and Children (WIC). There is also $400 million to assist local food banks to meet increased demand for low-income Americans during the emergency. The work requirement for the supplemental nutrition assistance program (SNAP) is also suspended. There are also provisions to provide funding and flexibility in the free and reduced lunch program if a school is closed for 5 consecutive days and for at home delivery of meals to the elderly.

The most important thing to remember is that payers have
differing definitions of what they consider telehealth. I recommend checking with the applicable
insurer for the most up-to-date information affecting requirements for coding
and billing of telehealth services. A
few things to ask about:

What are the effective dates? Most insurers are limiting this exemption to
a specific period of time.

What services are covered?

How are those to be billed?

Do we use telehealth codes or office visit
codes?

What place of service?

What modifiers are necessary?

For fee-for-service, traditional Medicare

The information below pertains to the major payers in
Alabama as of 3/18/2020 –

Blue Cross Blue Shield of Alabama is allowing
providers to bill for phone call treatment of existing patients under the
established patient office visit codes from 3/16/2020 – 4/16/2020. They are allowing codes up to 99213 with
place of service code 02 (zero two) for telehealth. No modifier is
required. Many providers are concerned
about reaching that level of service when no examination can be performed. Remember that established patient office
visits require only two of the three key components – history, examination,
medical decision-making. If the
physician documents an expanded problem-focused history and low complexity
medical decision-making, 99213 will be supported. This must be the physician speaking with the
patient, not the office staff.

Alabama Medicaid normally requires separate
credentialing for providers performing telehealth; however, that restriction
has been waived 3/16/2020 – 4/16/2020 (dates of service). Medical providers may bill established-patient
evaluation and management codes 99211, 99212 and 99213 for telephone
consultations. Psychologists and
behavioral health professionals should bill 90832, 90834, 90837, 90846, 90847
and H2011. A dental provider should bill D0140.
Place of service code 02 (zero two) for telehealth and modifier CR are
required. Verbal consent must be
obtained and documented in the medical record.
These visits will count against the patient’s office visit limit of 14
visits per year.

United Health Care is waiving originating site
restrictions for their commercial, Medicare Advantage, and Medicaid plans. The patient may be at home or at another
location. All the other requirements for
telehealth must be met – real-time audio and video communication system
required. These include the place of service 02 and the GQ (asynchronous
telecommunications system) or GT (interactive audio and video telecommunication
system) modifier. This waiver is only in
effect until April 30, 2020.

Medicare

Fee-For-Service Medicare DOES NOT allow telephone calls to be
billed as telehealth. The PHE waiver
provides three specific exceptions to the existing telehealth regulations:

the patient can be in their home or other
location – they do not have to be in a healthcare facility in a HPSA.

the audio-video link can be something as simple
as Skype or FaceTime or Facebook Messenger video calls – but it has to be a
real-time audio AND video one-to-one connection, not something public-facing

costshare can be waived – it is not
automatically, but it can be waived at the providers’ discretion.

This does include office visits, consultations, Transitional Care Management, and Annual Wellness Visits. Place of service is 02 (zero two) for telehealth. No modifier is necessary unless you are billing from a CAH Method II hospital (GT) or you are treating the patient for an acute stroke (G0). There is also a modifier for a telemedicine demonstration project in Alaska or Hawaii (GQ).

NOTE: Although CMS stated that no modifier is necessary, Palmetto GBA is requesting modifier CR be appended for tracking purposes.

For services that have a site of service differential,
payment will be made at the facility rate.

CMS has not specified an end date for these exceptions, just
that they will be allowed as long as the Public Health Emergency declaration is
in effect.

If there is not a real-time audio-video connection, then you
are limited to one of the following:

Virtual Check-In

G2012 – Brief communication technology-based
service, e.g. virtual check-in, by a physician or other qualified health care
professional who can report evaluation and management services, provided to an
established patient, not originating from a related E/M service provided within
the previous 7 days nor leading to an E/M service or procedure within the next
24 hours or soonest available appointment; 5-10 minutes of medical discussion

G2010 – Remote evaluation of recorded video
and/or images submitted by an established patient (e.g., store and forward),
including interpretation with follow-up with the patient within 24 business
hours, not originating from a related E/M service provided within the previous
7 days nor leading to an E/M service or procedure within the next 24 hours or
soonest available appointment

Please note the following restrictions:

Established patients only (same definition as
for other E&M services)

Verbal consent required and must be documented
in the patient’s medical record

No service-specific documentation requirements
but medical necessity must be documented.

May only be billed by those providers who can
perform and bill E&M services

To clarify – G2012 has been in effect since 1/1/2019 – it is
supposed to be for an established patient, but CMS has said they will not audit
for that requirement during this time.
It does not require the video link, so it is really the only option for
phone calls. It cannot be related to an
office visit within the past 7 days, as that would be considered part of the
work of the already-billed office visit.
And if the doctor tells the patient to come in at the first available
appointment, it can’t be billed as it would be considered the pre-work for the
upcoming office visit. As it specifies
5-10 minutes of medical discussion, time should be documented.

For email or portal communication, we also have these codes,
new for 2020:

#99421 – Online digital evaluation and
management service, for an established patient, for up to 7 days, cumulative
time during the 7 days; 5-10 minutes

#99422 – …11-20 minutes

#99423 – … 21 or more minutes

Please note the following restrictions:

Patient-initiated digital communications
requiring a clinical decision that would otherwise be made during an office
visit

Physician/Qualified Healthcare Professional
(QHP) time only

Not billable if patient seen in person or through
telehealth within 7 day period

For All Payers –

There have been questions on how to perform a visit by phone
or audio-video without being able to examine the patient. First of all, established patient visits
require two of the three key components:
history, examination, and medical decision-making. A visit can be billed based on history and
medical decision-making. However, some
examination can be done without laying hands on the patient. Observation can be done through video, and
sometimes just through audio. A
physician can observe skin tone, abnormal movements, respiratory effort and
many other exam elements without being able to necessarily touch the
patient. A complete Psychiatric exam can
be accomplished through talking with the patient.

For example, the patient calls in with complaint of dysuria.
The physician documents the complaint (Duration, Timing) and further asks
questions about fever, nausea and vomiting (Constitutional and Gastrointestinal
Review of Systems). He also reviews the
patient’s Past Medical History and Allergies.
Based on her previous history, he suspects that the patient has a
urinary tract infection and orders an antibiotic.

A patient with asthma calls in with an exacerbation – the
physician can actually hear the patient wheezing over the telephone – that
would be documented as a problem-focused examination.

The key point is that the physician himself must have the
conversation with the patient on the phone or through the audio-video link. This may be something that a nurse may have
handled previously, but now it must be performed by the physician to be
billable.

The Centers for Medicare and Medicaid Services (CMS) released its final rule for the CY 2020 Physician Fee Schedule. The Medical Association and the AMA will continue to review the rule and analyze these policies in the coming weeks. Attached is a summary of some of the policies CMS finalized in the rule.

Some of the highlights of the final rule are:

E/M Coding: Finalizes new E/M coding policy effective January 1, 2021. E/M codes for new patients will be 4 levels (CPT codes 99202-205) and for established patients, there will be 5 levels (CPT Codes 99211-99215)

Conversion factor: $36.09 resulting in a .14% increase in fees

Scope of Practice-Physician Supervision Requirements for Physician Assistants (PAs). CMS finalized its revisions to regulations on physician supervision for physician assistant services. The current policy requires general physician supervision for PA services, however, CMS’ revisions provide that the statutory physician supervision requirement for PA services is met when a PA furnishes their services in accordance with state law and state scope of practice rules for PAs in the state in which the services are furnished.

Physician Enrollment CMS finalized new authority to deny or revoke a physician’s enrollment if he or she has been subject to prior action from a state oversight board, federal or state health care program, Independent Review Organization (IRO) determination(s), or any other equivalent governmental body or program that oversees, regulates, or administers the provision of health care with underlying facts reflecting improper physician or other eligible professional conduct that led to patient harm

On October 9, 2019, the Office of Inspector General (“OIG”) and the Centers for Medicare and Medicaid Services (“CMS”) published proposed rules to revise the Stark Law, Anti-Kickback Statute and Civil Monetary Penalty Statute. These statutes create criminal and civil penalties for certain financial arrangements involving providers. According to OIG and CMS, the goal of the proposed rules is to address barriers created by the rules that interfere with care coordination. The additional safe harbors were necessary to allow for coordination of patient care among providers because of the increased focus on value-based care. Value-based programs reward healthcare providers with incentive payments for quality of care. Examples of these programs include Hospital Value-Based Purchasing, Hospital Readmission Reduction Program and Hospital Acquired Conditions Reduction Program.

Anti-Kickback

The proposed changes in the published rule include three new safe harbors for certain remuneration exchanged between or among participants in a value-based arrangement intended to foster better coordinated patient care. These include:

The proposed rule also offers a new safe harbor for certain tools and support furnished to patients to improve health quality outcomes and efficiency, such as health-related technology or patient health-related monitoring tools. Additionally, a new safe harbor is proposed for remuneration provided in connection with a CMS sponsored innovation model, which is intended to reduce the need for separate and distinct fraud and abuse waivers.

There is a proposed safe harbor for donations of cybersecurity technology and services as well as modifications to the existing safe harbor for electronic health records and services to add protections for certain related cybersecurity technology, to update provisions regarding intra-operability, and to remove the sunset date that previously existed.

The rule proposes a positive change to the Personal Services and Management Contracts safe harbor, by eliminating the requirement that periodic or part-time services be on a specific schedule or interval. Additionally, the safe harbor adds a provision for “outcome-based payments.” Outcome-based payments are those payments that reward the provider for improving patient or population health by achieving one or more outcome measures or that reduce payor costs while improving or maintaining the improved quality of care for patients.

Another existing provision related to warranties is updated to revise the definition of warranty and provide protection for bundled warranties for one or more items of related services. Local transportation is covered by an existing safe harbor, but the proposed change expands and modifies mileage limits for rural areas and for transportation for patients discharged from inpatient facilities.

Lastly, the Accountable Care Organization Incentive Program is added to the exception of the definition of “remuneration.”

Stark Law

The physician self-referral law, known as the Stark Law, has not been significantly updated since its enactment in 1989. The proposed changes seek to reduce the burden on physicians and allow for coordination of care.

Like the new safe harbors under the AKS, the proposed changes to the Stark Law include value-based arrangements. A value-based arrangement is defined as an arrangement for the provision of at least one value-based activity for a target patient population between or among the value-based enterprise (“VBE”) and one or more VBE participants or VBE participants in the same value-based activity.

Another update to the Stark Law includes a proposed change clarifying the existing provision that allows a physician in a group practice to be paid a share of the overall profits of the group that is indirectly related to the volume or value of the physician’s referrals. Additionally, there are changes to how the law treats productivity bonuses for physicians.

According to CMS, the intent of the proposed changes is to alleviate the fear physicians may have in entering into legitimate relationships to coordinate and improve care of patients.

CMP

There is only one proposed change for the Civil Monetary Penalty statute, and it adds a new statutory exception to the prohibition on beneficiary inducements for telehealth technologies furnished to certain in-home dialysis patients.

For all the proposed rules, OIG and CMS are seeking public comments, which are due December 31, 2019. For more information on the proposed rules visit https://oig.hhs.gov/compliance/safe-harbor-regulations/index.asp and https://www.cms.gov/newsroom/fact-sheets/modernizing-and-clarifying-physician-self-referral-regulations-proposed-rule.

Pursuant to a new rule, entitled Program Integrity Enhancements to the Provider Enrollment Process, the Centers for Medicare & Medicaid Services (“CMS”) is expanding its ability to combat fraud and abuse within the healthcare industry.

Under the new rule, CMS will be able to identify individuals and entities that pose a fraud and abuse risk solely based on “affiliations” with other entities that have been sanctioned by CMS. CMS can then take steps to prevent such identified individuals and entities from participating in the Medicare program. At the request of CMS, enrolling providers will disclose
any current or previous “affiliation” with an organization that has uncollected debt (regardless of amount and regardless of appeal status), experienced a payment suspension, been excluded, or had its billing privileges denied or rescinded (regardless of the basis). As used within the new rule, “affiliation” would include, among other things, an individual with 5% or greater indirect or direct ownership interest, officer, director, individual with operational or managerial control, or any reassignment relationship.

The provider community has expressed a number of concerns with this new rule, as the new rule gives a large amount of discretion to CMS without comparable notice or remedy to the provider. Consequently, in light of this new rule, Medicare providers and suppliers need to carefully and thoroughly examine any individual with whom it has an “affiliation” relationship to
avoid negative consequences.

Providers and recipients now have a new way to receive important information from the Alabama Medicaid Agency. The Text Messaging Service provides immediate and/or important communication directly to you. Examples of information shared with providers includes: approaching deadlines, new program announcements, required provider agreements, Medicaid meetings and training, office closures, or other vital information which may impact your practice.

We hope you will take advantage of this service to stay up to date. Subscribing is quite simple. Text ALPROVIDERS to 888777 to receive provider notifications. You can opt-out at any time. Please note that recipients have a separate keyword and text messaging list to subscribe to in order to receive important recipient information from the Agency.

The Agency will continue to provide regular communication through the Provider Insider newsletter, the Medicaid website, the subscription-based electronic mailing list and Alerts. For additional information about the Text Messaging Service for Medicaid, please visit www.Medicaid.Alabama.gov or call (334) 353-9363.

The end date for the Patient 1st Program is approaching, and providers will be required to have completed agreements with both Medicaid and the ACHN. Primary Care Physicians (PCPs) will no longer receive Patient 1st capitation payments beginning in October 2019. The ACHN program will be implemented on October 1, 2019, and providers will need to complete ACHN agreements as soon as possible and before July 1, 2019, to avoid any delay in receiving bonus and participation payments.

The Alabama Department of Public Health Meaningful Use team recently added new functionality where Eligible Providers who are currently participating in the PI Program can access the PDMP registry and run reports to show that they are actively engaged with this Specialized Registry during the reporting period. This documentation is required to meet the Public Health objectives and measures and can be submitted with the EP’s application for the Program Year for which they are attesting.

If you have technical issues with accessing and generating this report, please contact ADPH Helpdesk at 1-855-925-4767, Option 1.

Complete Your ACHN Agreements Before July 1

Primary Care Physicians (PCPs) will not be receiving a capitated payment in October 2019. The Alabama Coordinated Health Network (ACHN) program will be implemented on October 1, 2019, and providers will need to complete ACHN agreements as soon as possible before July 1, 2019, in order to receive bonus and participation payments. The end date for the Patient 1st Program is approaching, and providers will be required to have completed agreements with both Medicaid and the ACHN.

Higher doses of opioids are associated with higher risk of overdose and death – even relatively low dosages (20-50 MME per day) may increase risk.1 Therefore, Alabama Medicaid will limit the amount of cumulative MME allowed per day on opioid claims. The edit will begin at 250 cumulative MME per day and will gradually decrease over time. The final cumulative MME target is scheduled to be 90 MME per day. This edit is different, and in addition to, the short-acting opioid naïve edit implemented on November 1, 2018.

Phase-In Period:
Beginning May 1, 2019, Alabama Medicaid will begin with a “phase-in” period for 3 months. Claims that exceed the cumulative daily MME limit of 250 MME will be denied at the pharmacy Point of Sale (POS). The dispensing pharmacist will be provided a universal prior authorization (PA) number on the rejection screen and may enter this universal PA number on the claim to allow it to be paid. Pharmacists are urged to notify the affected patient/prescriber to develop a plan to decrease the patient’s total daily MME.

Hard Edit Implementation:
Beginning August 1, 2019, opioid claims that exceed the cumulative MME edit of 250 MME/day will be denied. The universal PA will no longer be valid to bypass the 250 MME edit. Pharmacy override requests for quantities exceeding the MME limit may be submitted to Health Information Designs (HID) and will be reviewed for medical necessity. See link below for override form.

Edit Details:

The universal PA number to override the 250 MME edit will be 0009996321

The universal PA number will be provided on each cumulative MME rejection screen for the pharmacist convenience

Additional edits such as therapeutic duplication, maximum quantity limitations, early refill, non-preferred edits will still apply

Anticipated Phase Down:
The Agency anticipates gradually decreasing the daily cumulative MME limit every 4 months. The first decrease to 200 MME/day will be implemented on December 1, 2019. Prior to each decrease, a new universal PA number will be assigned to override claims that exceed the new threshold. Providers will be notified via an ALERT prior to each decrease. Again, pharmacists are urged to notify the affected patient/prescriber to develop a plan to decrease the patient’s total daily MME.

IMPORTANT: Only if the override is denied, then the excess quantity above the maximum unit limit is deemed a non-covered service, and the recipient can be charged as a cash recipient for that amount in excess of the limit. A prescriber must not write separate prescriptions, one to be paid by Medicaid and one to be paid as cash, to circumvent the override process. FAILURE TO ABIDE BY MEDICAID POLICY MAY RESULT IN RECOUPMENTS AND/OR ADMINISTRATIVE SANCTIONS. Source: Provider Billing Manual 27.2.3

ORIGINAL ARTICLE April 2019: In addition to the opioid naïve 5 and 7-day limits, the Alabama Medicaid Agency is working toward implementing cumulative Morphine Milligram Equivalent (MME) edits in early 2019.

Higher doses of opioids are associated with a higher risk of overdose and death; even relatively low dosages (20-50 MME per day) may increase risk.1 Alabama has led the nation for the past six years in the opioid prescribing rate per 100 population (121 in 2016; 107.2 in 2017) and had nearly three times more opioid prescriptions per 100 population than New York.2

The Alabama Medicaid Agency previously executed many programs to address opioid use such as monthly maximum unit limits, therapeutic duplication edits, Drug Utilization Review (DUR) letters, academic detailing report cards and face to face visits, prior authorization, and other educational efforts. Most recently, Medicaid implemented limits for opioid naïve patients to limit first-time use to five days for children and seven days for adults, limiting daily use to 50 MME. Overrides are available for medical necessity.

In an effort to continue combating the opioid crisis, beginning May 1, 2019*, Alabama Medicaid will limit the amount of cumulative MMEs allowed per day on claims for opioid experienced recipients. The edit will begin at 250 cumulative MME per day and will gradually decrease over time. The final MME target is 90 MME per day.

Claims for opioids that exceed the maximum daily cumulative MME limit will be denied. Claims prescribed by oncologists will be excluded from the edit. Long term care and hospice patients will also be excluded; however, children will be included. Overrides for quantities exceeding the MME limit for medical necessity may be submitted to Health Information Designs (HID). Information regarding override requirements and MME examples will be made available on the Alabama Medicaid Agency website closer to the implementation of the new limitations.

The Agency will implement a robust educational program to include academic detailing visits to the prescribers and pharmacies of the first round of affected patients, extensive training, and notifications to the impacted providers through a provider ALERT closer to implementation. Please check the Alabama Medicaid Pharmacy webpage for additional information: http://www.medicaid.alabama.gov/content/4.0_Programs/4.3_Pharmacy-DME.aspx

*At the time of article submission, the implementation date is May 1, 2019, for a ‘phase in’ for 250MME/day. During the phase-in period, a universal prior authorization number will be provided on the pharmacy claim rejection, with an explanation to notify the affected patient/prescriber. Hard stops/edits will begin after the phase-in period.